Regional Anaesthesia in the Critically Ill

OVERVIEW

  • multiple techniques for various situations

ADVANTAGES

  • reduced opioid to achieve analgesia – less respiratory depression, especially in chest injury or high risk of respiratory failure (elderly, COPD)
  • laparotomy -> supreme analgesia, improved respiratory function (The MASTER trial), decrease in arrhythmias and acute coronary syndrome
  • can be used to minimise opioid consumption and thus troublesome side effects (N+V, constipation, ileus with subsequent aspiration or enteral feed intolerance)
  • less interference with mental status
  • reduced used of non-opioids: NSAIDs -> renal impairment, platelet dysfunction, tramadol -> confusion in the elderly, ketamine -> hypertension, tachycardia, dissociative effects.

DISADVANTAGES

Patient and critical illness factors

  • often redundant in sedated, ventilated patients
  • not proven in critically-ill to better in terms of outcome -> not a lot of strong evidence to support its use
  • may still need opioids
  • difficult covering multiple sources of pain
  • may alter signs in compartment syndrome
  • monitoring of blockade in uncooperative patient maybe impossible
  • removal with DVT prophylaxis may be an issue

Procedure factors

  • technical expertise required
  • need for patient positioning
  • anatomical land-marks may be difficult

Complications

  • related to placement (vascular injection, pneumothorax, neurological injury)
  • LA toxicity risk (especially with brachial plexus, pleural catheters)
  • sympathectomy -> another reason for a critically unwell patient to by hypotensive
  • problems with coagulopathy -> epidural haematoma
  • catheters over longer term -> risk of infection
  • confused patients are more likely to dislodge catheters
  • may fail (patient exposed to risk but no benefit)

References and Links

Textbooks and journal articles

  • Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007 Mar;104(3):689-702. PMID: 17312231.
  • Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS; MASTER Anaethesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002 Apr 13;359(9314):1276-82. PMID: 11965272.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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